Medicines optimisation for older people with disabilities

Transcription

1 Medicines optimisation for older people with disabilities Riddhika Joshi Care of older people and stroke pharmacist

2 Objectives Medicines Optimisation Examples Identifying patients PREVENT Targeting patients in the hospital this includes frailty as a measure - PREVENT Examples Frailty Examples

3 Medicine optimisation 1 Address the patients needs establish if person and/or carers have any concerns or questions Patient Experience Evidence based Check there is a clear and valid reason and appropriate monitoring and reviews Discuss individualised treatment goals Safe and effective Routine practice Ask patients about what simple changes they think will improve adherence such as the formulation or frequency of administration

4 PREVENT 2 Tool developed at LNWH to identify high risk patients

5 How are frailty and medicines issues linked? 3,4 Clinical frailty Scale Care of Elderly ward patients Review polypharmacy Optimise medicines management

6 Slide 5 GDPu6 Could mention some recent work done on COE, where we looked at the fraility score for each patient and then what we do for that patient. So for patients with a score of less than < 6, check who manges the medicines, ensure each medicine has indication and is titrated to the correct dose - ensure no underdosing. If medicines havent been charted e.g. paitent has ACS but not on statin query why. Ratioanlise the medicine regimen with view to treat PMH Generic Default PCS user, 28/10/2016

7 Medicine optimisation in frailty Medicines review to ensure only on essential medicines relevant to patients clinical condition Shared decision with the doctor to rationalise medicine and consideration for LCP

8 Slide 6 CR1 For people with a frality score >6 rationlaise medicines with a view to stop, check who is managing the medicines. Catherine Rigby, 03/11/2016

9 Acute care setting Physical Impairment and Frailty Example One 79 year old Male, admitted with a fall. Background: Hypertension, AF, Type1DM, High cholesterol Social History: Lives alone with OD PoC and registered blind Frailty Score: Mildly Frail (6) Obervations: BP: 130/60 BM: average: 6-8 HR: 90 U&E : unremarkable Medicines: Insulin Innolet 5 units in the morning and in the evening Amlodipine 10mg in the morning Ramipril 10mg in the morning Bisoprolol 2.5 mg in the morning Atorvastatin 20mg at night Hypromellose eye drops 0.3% 1 drop into each eye 4x day Patient referred as pharmacist believe the patient will not be able to manage medicines especially the insulin.

10 Slide 7 GDPu1 Is this examples of PREVENT referrals. Mention that in hospital we can complete an electronic referral for diabetes could the blood pressure tablets be rationalised Generic Default PCS user, 28/10/2016

11 Example One - continued Identifying how patient was managing prior to admission Self managing Insulin managed with listening to click on the innolet Referred to the Diabetic nurse specialise via an electronic referral system To ensure not on appropriate dosing and falls are not a result of hypoglycaemia Optimising Hypertension medications Ramipril - Stopped (BP stable) Bisoprolol - changed to night Amlodipine - in the morning Splitting timings of antihypertensive to reduce risk of falls

12 Acute Care Setting Adherence Issues Example Two Mr JW referred by the ward pharmacist as refusing all medicines and brother concerned he not take medicines at home On assessment No capacity to make financial decisions but still had capacity to refuse carers and medicines I am 87 years old and I want to die peacefully I don t need medicines Drs adamant to give him meds. He refused. What do we do??? Discharged without medicines readmitted due to clinical condition (no carers and worsening of clinical conditions) Now waiting for placement as agreed he cant manage NOTE people are allowed to make decision you don t agree with (and maybe even you think are foolish). We all are.

13 Acute care setting Adherence Issues and Medicine Compliance Aids Example Three Most referrals made for medicine compliance request 5 Referral often made by OTs /Pharmacists/ Family members Electronic Referral system on ICE order comms launched in September Patient referred due to social issues a) Lives alone and carers administer medicines 2. Physical impairment 3. Monitoring adherence Liaising with : Patients Carers (Formal/informal) Community Pharmacist GP s

14 Optimising medicines: Cognitive support Dementia What is happening at home Delirium Acute onset no previous issues (so no carer support pre admission) may last post admission (6 weeks) who will support? Capacity Difference in capacity to take meds vs choose cup of tea vs make financial decision (activity and time dependent) Role of carers

15 New Diagnosis/Exacerbation of disease and Medicine related admission Example Four Mrs SF 78, admitted to hospital for the 3 time due to exacerbation of asthma Lived alone and spoke very little English Carers 3 x a week Medicines all prescribed as per the BTS guidelines Salbutamol 100mcg/dose evohaler 2 puffs qds prn Seretide 250 evohaler 2 puffs BD Complete 2 courses of prednisolone Montelukast 10mg Daily (new started on second admission as asthma not controlled) Discharged from acute ward

16 Example Four continue Identified during the medicines reconciliation process as high risk patient Inhaler technique assessed on admission Patient not counselled appropriately on inhaler technique Due to language barriers On discharge counselled in the patients language Provided with aerochamber with a mask Montelukast stopped GP contacted to assess patient in 3 months

17 Cultural and Social Issues Example Five Mr S, 50 year old male admitted with stroke Amlodipine 10mg Daily on admission Intentional non-adherence Social Issues: Smokes 40 60cigs/day Uses recreational drugs Consumes 4 6 units of alcohol each day No Fixed Abode as recently divorced Not registered with GP Patient referred due to non adherence to antihypertensive

18 Example Five Continued Referred to the Psych Liaisons Teams Management of Drugs and Alcohol Referred to community outreach team Started on Nicotine Replacement Therapy (NRT) referred to local community pharmacy Re-registered with GP surgery

19 Tips to take home Reduced morbidity and mortality in frail adults through meds optimisation can be supported through: Identifying who is frail they are more at risk of meds related problems than non frail patients Recognising which medicines are highest risk (use validated tool e.g. STOPP/START Work with patient and carers to manage the most important problem from a shared (collaborative) perspective Implement/advise patient, carer and relevant clinical staff on potential for deprescribing and appropriate polypharmacy

20 References 1. Royal Pharmaceutical Society. Medicines optimisation Briefing. [Accessed October 2016] 2. Scoring-is-based-on-clinical-judgment-Reprinted-with [Accessed October 2016] 3. Fried LP Tangen CM Walston J et al. Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci Mar;56(3):M [accessed October 2016] 4. British Geriatric Society. Fit for Frailty. Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. June [accessed October 2016] 5. N. Barnett, K. Dave, P. Parmar, D. Athwal, S. Kaher, C. Ward,Impact of an integrated medicines management service on preventable medicines-related readmission to hospital: a descriptive study. September [Accessed October 2016]

21 Optimising medicines: Physical support Dexterity Pill mates, Non CRC bottles, Haler-aids Sight impairment What is the degree of impairment Patients own glasses, magnifying glass Braille on the box Hearing impairment Hearing aids - are they there/working? Sign language?

22 Slide 18 GDPu2 Can this slide be incorporated into an example and keep it practical to hospital Generic Default PCS user, 28/10/2016